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An Executive Seat at the Compliance Table

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C-suite involvement in a North Dakota system's compliance group meetings leads to both a cultural shift and a smoother Joint Commission survey process.

Compliance group meetings at Altru Health System in Grand Forks, ND, include an unusual sight—either the executive director or chief operating officer of the system sits at the head of the table.

"Leadership has to take a very active role in the [Joint Commission] process," says Tim Sayler, executive director of Altru. "What we've done is made sure that either myself or our COO [Dave Molmen] are in attendance at all quality-related meetings, including anything involving The Joint Commission."

In fact, they chair those meetings. Usually only one of the two men is in attendance, and he acts as chairman.

The senior leaders' presence started with a less than ideal survey.

"We weren't entirely pleased with how our last survey went," says Sayler."We felt in part it was a cultural issue, and that our leadership group and those who work on those processes needed to see more of a leadership presence there."

The hospital has traditionally done well on surveys, Joint Commission and otherwise, but officials were not satisfied with the latest results. This led to a shift in thinking.

"We reorganized ourselves a bit. We'd always had a compliance group and committee, but we set it up so that we had chapter chairs and teams of individuals in charge of compliance across the organization," says Sayler.

Individuals were in charge of a particular chapter and would report progress back to the broader committee. Rule number one: Talk about the good and the bad.

"We don't just want to hear the good stuff," says Sayler. "We want to hear about the issues. We want an environment created where it's OK to have warts, areas where we're not in compliance, so that we can recognize those areas and create action plans to fix them."

In the past, there was a tendency to view the survey process as something The Joint Commission was forcing the hospital to do, says Sayler. This viewpoint still arises once in a while, but primarily the facility has seen a change in its staff toward a belief that they are doing the right thing in terms of safety and quality.

Engaging leadership
For Sayler and Molmen, taking an active role in the accreditation process just made sense. Still, it's a rare sight to see high-level leadership roll up their sleeves in this manner.

"I would tell my peers that it doesn't take that much time," says Sayler. "I do have peers that tell me they don't get involved, because the process is seen as more operational. In some regards it is, but if you're at the level where we felt we've been, building a culture of quality, that requires leadership commitment. You have to somehow be engaged, show you support that culture, understand it, and provide resources to help improve quality."

It's easy for leadership to get sidetracked, he says. "In the C-suite you have a lot of distractions," says Sayler. "If it's not finance, it's competition … there are many distractions. But in the past, quality hasn't been as much of a topic that people work on actively in the C-suite. It's more in the public eye and something we need to be engaged in."

"Being engaged in that committee and being responsible to know all the leadership chapter components as well as who needs to be involved … my knowledge of The Joint Commission, the accreditation process, standards, and the workings of accreditation have improved significantly," says Sayler. "This is an area where we've always had knowledgeable leadership, but the task has been delegated to those who work in those areas."

Building a better board
During the reorganization period, the organization brought a board member onto the quality council. "We are working toward reporting quality as much as we report finance," says Sayler.

The group sat down and examined the composition of The Joint Commission or Compliance Committee and increased its membership to roughly 20 professionals from all aspects of the hospital. "It's a good way to see if we're having issues," says Sayler. "It really helps not just being responsible for a chapter, but getting things that need to be done across the organization."

Where does the power of leadership involvement come into play? When one particular issue was lagging behind in being resolved, for example, the leadership made it a point to not lay blame, but they pulled aside the chapter leader.

"We said, ‘It doesn't just start and end in your department,'" says Sayler. "The service you provide goes through all departments."

Senior leaders' influence can also be as simple as making a phone call.

"Someone might call me to say, for example, ‘We're going to the medical executive committee next week and we want some medical record documentation and it's taking too long to receive those reports,'" says Sayler. "The other department doesn't want a phone call from me. I've never made a phone call like that a second time. But it shows them that we've put a process in place and we're watching. We're not going to come down on them, but if there's a problem … it will be fixed."

The system has reached the point where the culture is less about "the boss is watching" and more one of continuous compliance, he explains.

"It should be happening whether I'm there or not," says Sayler. "I think we'd see if I wasn't in attendance, [the right results] would still be happening. But there is a certain amount of focus in that people know we're watching. We're seeing results, and we know it's happening."

Involving physicians
"We've brought our physician leaders into this," says Sayler. "We have our chief medical officer and executive medical director in attendance when possible."

Both were receptive to taking on a greater level of involvement in the accreditation process. "They like the meeting because it gives them a real snapshot of how we're doing in a lot of quality areas," says Sayler.

The format of the meeting is a series of quick hits and rapid reports with some discussion about how improvement or change will happen. "After one hour, we walk away with a feeling that we've got a great overview of where we're at," he says. Although major improvements have been made, Altru is still taking the approach that the learning process is never finished.

"Being compliant, working on quality and improvement, for me we're taking the approach as a journey," says Sayler. "Part of the culture you've got to instill in people is that we're never just done. We need to continuously work on this. You don't just want to achieve something. We want to achieve it, hold the gains we get, and sustain them over time."


This story is from Briefings on The Joint Commission, a publication of HCPro Inc., the parent company of HealthLeaders magazine.

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